| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $5 | $5 | $5 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $3 | $4 |
| Allergy testing insect venoms CPT 95017 • Allergy | $3 | $5 | $7 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $19 | $19 | $19 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $7 | $7 | $7 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $14 | $14 | $14 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $40 | $40 | $40 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $40 | $40 | $40 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $954 | $954 | $954 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,684 | $1,684 | $1,684 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $3,419 | $3,419 | $3,419 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $2,102 | $3,058 | $4,014 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $2,342 | $2,342 | $2,342 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $477 | $477 | $477 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $20 | $20 | $20 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $5 | $5 | $5 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $7 | $7 | $7 |
| Cardiovascular stress test CPT 93015 • Cardiology | $64 | $64 | $64 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $30 | $30 | $30 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $71 | $71 | $71 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $100 | $100 | $100 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $212 | $212 | $212 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $186 | $186 | $186 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $227 | $227 | $228 |
| Stress echocardiography CPT 93350 • Cardiology | $176 | $176 | $176 |
| Left and right heart catheterization CPT 93452 • Cardiology | $215 | $215 | $215 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $1,080 | $1,080 | $1,080 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $112 | $112 | $112 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $228 | $228 | $228 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $54 | $93 | $132 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $151 | $151 | $151 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $187 | $187 | $187 |
| Punch biopsy of skin single lesion CPT 11104 • Dermatology | $232 | $232 | $232 |
| Incisional biopsy of skin single lesion CPT 11106 • Dermatology | $217 | $252 | $287 |
| Shaving skin lesion trunk/arms/legs 0.5cm or less CPT 11300 • Dermatology | $109 | $125 | $141 |
| Shaving skin lesion trunk/arms/legs 0.6-1.0cm CPT 11301 • Dermatology | $170 | $197 | $225 |
| Shaving skin lesion scalp/neck/hands/feet 0.5cm or less CPT 11305 • Dermatology | $71 | $71 | $71 |
| Shaving skin lesion face 0.5cm or less CPT 11310 • Dermatology | $83 | $83 | $83 |